Drug stock-outs: Inept
supply-chain management and corruption

The National Health Department is urgently
trying to source and install a countrywide computer software
system that will link healthcare facilities with drug depots and
suppliers in order to relieve ongoing essential drugs stock-outs
which threaten the lives of thousands of patients. The issue has
become a national crisis, affecting districts in 8 of the 9
provinces.

Contributing factors include a shortage of pharmacists,
protracted labour disputes, dismal management, corruption, and
woeful communication between suppliers, depots and facilities.
Reports from HIV clinicians and fieldworkers, plus a collective
probe by 4 influential NGOs, reveal that only adept clinical
management of patients is preventing the emergence of widespread
drug resistance and a rise in morbidity and mortality. According
to the NGO report – compiled by the Rural Health Advocacy
Project, Médecins Sans Frontières, the Treatment Action Campaign
and +Section 27 – one of the worst examples is the Mthatha
depot. In November last year the depot was described as
‘anarchic and beyond redemption’ by the then Eastern Cape Health
Superintendent General, Dr Siva Pillay. This January, 24% of
drug-prescribed patients were turned away from the 300
facilities the depot serves across 17 districts of the sprawling
Oliver Tambo region, while 53% of the clinics and hospitals it
serves suffered antiretroviral (ARV) or tuberculosis (TB) drug
stock-outs, including shortages of the new fixed-dose
combination (FDC) ARVs. These stock-outs lasted on average 45
days at a time and remained ‘almost as common and severe as they
were 5 months ago’, according to the report.

Former health chief: ‘Shut it down, bring
in the army’

An estimated 100 000 patients depend on the Mthatha depot for
their ARV drug supplies – giving some idea of the potential
impact of similar dysfunctional facilities nationwide. The
report found that the Eastern Cape Health Department’s
suspension of 29 depot staff late last year, without a plan to
provide services in their absence, contributed significantly to
the crisis. At the time of writing, the depot still had no
full-time manager and was operating with half its usual number
of staff.

There were other reasons
for the province’s stock-out crisis. Between May and November
2011, 19 tons of medicines stored at the Mthatha and Port
Elizabeth depots, plus the province’s 92 healthcare
facilities, were destroyed after being ‘tampered with’ or
because they had passed their expiration dates. Earlier in
2011, 16 tons of medicines and surgical products were
destroyed in a fire allegedly set at the Mthatha depot after
Pillay ordered a sudden audit of the facility. In a ‘sting’
operation by the Hawks police unit, 3 health department
pharmacy assistants and a municipal official were later
arrested and a municipal vehicle impounded, in connection with
the ‘theft-for-sale’ of an estimated R220 000-worth of
medications from this and a nearby depot. According to
documents in Izindaba’s possession, the Mthatha depot
issues a monthly average of R24 million worth of stock;
however, from mid-September to December last year, it issued
just R4 million worth.

In a November 2012 report Pillay described the depot as
‘unmanageable and unnecessary’ because it was ‘rife with
corruption, widespread theft and labour problems’. He proposed
bringing in the army to stem ongoing losses, which he estimated
at R250 million a year, replacing the removed staff with
temporary staff (to catch up on the month-long backlog), and
then shutting the depot down entirely, moving operations to Port
Elizabeth. In the long term, he proposed implementing, as a
pilot project, the national health department’s intended
strategy of getting suppliers to deliver directly to healthcare
facilities. His proposals were vetoed by his political
superiors.

Eastern Cape Health MEC Sicelo
Gqobana surveys R220 000 worth of medicines stolen from
the Mthatha depot in May 2011. The red municipal van was
used to transport the drugs.

Not just HIV
and TB meds

The NGO probe found that, nationally, mismanagement exacerbated
a chronic cycle of over-ordering by health facilities as the
result of poor stock-keeping. In many cases, orders are
radically out of step with actual need. The ‘vicious cycle’ is
amplified by national drug shortages, leading to rationing of
supplies to depots, which then adjust orders from facilities
downwards.

The probe also found that it’s not only HIV and TB drugs
running out across most provinces, but also a ‘wide range’ of
essential medicines. Both large and small facilities are
affected, with the latter particularly vulnerable as they are at
the end of the supply-chain management line, and suffer from
mistakes accumulated along the way. Lamivudine and tenofovir
were the ARVs most frequently out-of-stock nationwide.

The frequency of individual stock-out reports, combined with
the assessment of those on the ground, suggest that Gauteng is
also particularly badly affected, with patients reporting
province-wide shortages of lamivudine and, to a lesser extent,
tenofovir. Reports reaching the NGOs and other civil society
organisations suggest that this is ‘the tip of the iceberg,’
because many stock-outs and their impact have gone unreported.
In Ekurhuleni, at least 8 clinics were affected by lamivudine
and tenofovir stock-outs. KwaZulu-Natal’s Eshowe Hospital
reported low supplies of tenofovir and ‘indications of stock
mismanagement’ from the hospital to its surrounding clinics,
which also reported FDC shortages and stock-outs of paediatric
ARV dosages. In Limpopo, Messina Hospital ran short of
tenofovir, lamivudine was out of stock at the province’s main
depot and stavudine was in short supply at several health
facilities. The only province to escape mention in the damning
report was the Western Cape.

Confronted with drug shortage claims from HIV clinicians in
Gauteng, and elsewhere, Dr Yogan Pillay, National Deputy
Director General for HIV/AIDS, TB, Maternal, Child and Women’s
Health, accused facilities of ‘hoarding’ drugs. However, he
admitted that his department does not know individual
facilities’ stock levels. ‘Where there are facility stock-outs
we look at who else has supplies. Often the depot has to look
for stocks. From a national perspective we know exactly what’s
short, but we have no way of knowing what’s happening at
facilities. We also get figures from suppliers. Depot supplies
we have a fix on, but facilities – zero,’ he admitted. He said
the department is trying to install a system that will link
facilities’ computer software with that of depots and suppliers
to enable better management.

He rebuffed claims by Professor Francois Venter, the deputy
executive director of the University of the Witwatersrand (Wits)
Reproductive Health and HIV Research Institute and former head
of the South African HIV Clinician’s Society, that drug
stock-outs were responsible for a near-riot late last year among
patients at the Wits Esselen Street Clinic in Hillbrow, which is
mainly attended by sexworkers. Yogan Pillay said, ‘[The
clinic’s] problem is they don’t know how much to order on a
month to month basis – and their clients come from all over the
place.’

Venter scoffed at this, saying ‘We know exactly what to order.’
He pointed out that the problem extends to the province and
entire country.

Professor Francois Venter, deputy executive
director of the University of the Witwatersrand Reproductive
Health and HIV Research Institute. Picture: Chris Bateman.

Accountability like ‘chasing ghosts’

Added Venter, ‘The reasons are probably quite complex, but it
all comes down to management of the supply chain. It’s
frustrating that you never know who to blame or hold
accountable. Patients suffer. I must admit I have yet to see ARV
resistance or patients dying because of a lack of drugs – it may
be hidden and they’re dying at home – but it’s only a matter of
time before it happens.’

He cited one case in which a clinic manager had 2 000 patients
on treatment , while the depot reported enough drugs for only 1
000. Meanwhile another clinic got supplies for 3 000 patients –
when they had only ordered for 1 000. ‘You get the strangest
reports, and it’s not just ARV’s. We’ve run out of meningitis
drugs, antibiotics. OK, last year one drug company fell over and
couldn’t do the volumes, but in most cases the drugs just don’t
get from the depot to the patient. I feel really sorry for the
healthcare workers who have to explain to people and try and
make a plan.’

The HIV Clinicians Society
recently drew up a drug substitution guideline list, but
stock-outs leave diabetic or hypertensive patients instantly
vulnerable. Venter said he believed the National Health
Deparment ‘has huge frustrations with the provinces – everyone
at national [level] says this is indefensible. That’s great,
but it doesn’t help! I think there’s very limited
accountability. Public sector salaries are good, so it’s just
notOK that systems are failing, or to
whine about insufficient staff. We got this right with less
staff and relatively less pay five years ago. Things were
working. Twenty years ago things were working very well. It’s
got much worse.’ Venter said this is ‘particularly sad’
because the ARV programme has been ‘such a massive success’.

Asked about stock-outs of the much-touted new FDCs, Venter
questioned how effective healthcare worker education is
regarding FDC dispensing guidelines. He explained that
HIV-positive pregnant women and new patients are supposed to be
prioritised for FDCs. ‘It seems they [clinic staff] would
realise that having done this [priority dispensing], there were
lots of drugs left over, so they transitioned chronic patients
across – and that’s when the stock-outs crisis started.’

Understanding supply and demand ‘vital’

Venter’s theory is supported by the combined NGO report on the
stock-outs, which predicts that competent management of single
ARV drug stocks will be vital as increasing numbers of patients
experience FDC contra-indications (e.g. renal dysfunction) or
first-line ART failure. ‘The management of single drug stocks
may become more difficult and stock-outs of these options may
increase over time as stocks get smaller.’

The report said that ‘just months’ after the national
[priority-phased] roll-out of FDCs in April this year, shortages
were already being reported. A major and unexpected cause was
that manufacturers were producing below capacity because of
‘machinery updates’, and as a result some health facilities were
getting very small quantities of FDCs, insufficient to meet the
needs of the ‘priority groups’ (i.e. new ARV patients,
HIV-positive pregnant women and ‘triple-therapy stable’
breastfeeding mothers). The report warned that as more patients
became eligible for FDC, vigilance would be needed to ensure an
adequate supply.

State dysfunction costing patients jobs

The NGO report said that some patients are also beginning to
lose their jobs after taking every Thursday off over several
weeks in the vain hope of securing ARV drugs. Among the dramas
surrounding the stock-outs was a ‘sit-in’ by 50 patients at the
Village Clinic in Lusikisiki, Eastern Cape, who’d been told that
the ARV efavirenz was out of stock and that there were
insufficient FDC drugs.

The Democratic Nursing Organisation of South Africa, (DENOSA)
reported that angry patients are labelling its members as
‘uncaring professionals that deprive patients of medication’,
and called for the Public Protector to urgently probe the drug
stock-outs.

Gauteng provincial spokesman Chris Maxon blamed the shortage on
‘supplier capacity challenges’, while the province’s Health MEC
Hope Papo visited Daveyton clinics to check on reported
improvements. Papo promised that ‘in time’, adherent patients
who were in a stable condition would get 3-month supplies of
drugs to minimise travel costs.

The compilers of the NGO report confirmed that the national
health department plans to implement direct deliveries to
facilities, bypassing depots, with pilot projects underway in
Limpopo and KwaZulu-Natal. However, they warned that this will
probably only be practical for large deliveries. The department
is also considering direct deliveries to the patients’ homes or
for collection in stores, with pilot projects planned next year.
The collective report singled out the Eastern Cape health
department for its harshest criticism, saying it seemed ‘unable
or unwilling,’ to address drug supply problems in spite of
knowing of them for several years, and having ‘immense support’
from civil society. It suggested that national health minister
Dr Aaron Motsoaledi use his constitutional powers to intervene
on an emergency basis to bring health services back in line with
national standards.